Reverse Epidemiology and the Obesity Paradox for Patients with Chronic Kidney Disease: A Markov Decision Model

Abstract Background Obesity has been associated with both increased progression of chronic kidney disease (CKD) as well as with a paradoxical improvement in survival among end-stage renal disease (ESRD) patients undergoing hemodialysis. As such, the optimal weight management strategy for obese CKD patients remains unclear. Objective To estimate the outcomes of obese, CKD stage 3b patients following three weight loss interventions: medical weight management (MWM), sleeve gastrectomy (SG), and RYGB (RYGB) to determine which strategy optimizes long-term survival. Setting University hospital, Aurora, Colorado Methods A decision analytic Markov state transition model was created to simulate the life of 30,000 obese patients with CKD stage 3b, as they progressed to ESRD, transplantation, and death. Life expectancy following conservative MWM, RYGB and SG were estimated. Base case patients were defined as being 50 years old and having a pre-intervention BMI of 40 kg/m2. Sensitivity analysis of initial BMI was performed. All Markov parameters were extracted from literature review. Results RYGB and SG were associated with improved survival for patients with pre-intervention BMI of > 38 kg/m2. Compared to conservative weight management, base case patients who underwent RYGB gained 10.6 months of life, and gained 8.3 months of life following SG. Conclusions Balancing progression of CKD with improved survival on ESRD for obese patients requires selective use of weight management strategies. RYGB and SG improved survival for CKD patients with Class II and III obesity, but not for patients with Class I obesity. As such aggressive weight loss interventions should be reserved for patients with Class II and III obesity, while more conservative methods should be offered to those with Class I obesity.